Barriers to cognitive screening in acute stroke units

The Montreal Cognitive Assessment detects cognitive deficits that go unnoticed during clinical observation in the acute phase after stroke

BACKGROUND

Detecting cognitive impairments early after stroke is essential for appropriate referrals. Although recommended in stroke guidelines, early cognitive screening is not always implemented. We assessed whether the Montreal Cognitive Assessment (MoCA) adds diagnostic value compared to clinical observation alone. In addition, discharge destinations for stroke patients with and without cognitive deficits detected with the screening tool or the treatment team were explored.

METHODS

Forty-four stroke patients were screened with the MoCA during stroke unit admission. Their charts were studied for cognitive impairments reported by the stroke care team, who were blinded to screening scores. Proportions of detected cognitive deficits were compared between screening (score <26) and patient charts. Discharge destination distribution (home vs. rehabilitation) was explored.

RESULTS

The proportion of cognitively impaired patients indicated by the MoCA (84%) and reported in patients' charts (25%) differed significantly (p < 0.001). The distribution of discharge destination did not suggest an association with the detection of cognitive deficits by the treatment team or the cognitive screening.

CONCLUSIONS

The MoCA detects more cognitive deficits than clinical impression alone, emphasizing the importance of standard screening for cognitive impairments in acute stroke patients. Ultimately, systematic screening may enhance discharge planning and improve long-term outcomes.

Current Practices and Attitudes of Cardiac Nurses Regarding Cognitive Screening in Patients With Acute Coronary Syndrome

BACKGROUND

Cognitive impairment (CI) is common in patients with acute coronary syndrome (ACS) but is often undetected and may affect recovery and secondary prevention uptake. Nurses play a crucial role providing care for patients with ACS and promoting secondary prevention.

AIM

This study aimed to explore current nursing practices and barriers regarding CI screening in patients with ACS.

METHODS

Cardiac nurses were recruited from three metropolitan teaching hospitals and two professional associations in Australia and undertook a 38-question purpose-built survey.

RESULTS

A total of 95 nurses participated (mean age 38±13 years; 78% [n=74] female): 69 were registered nurses, and 48% had received CI training. Only 16% of nurses in our sample reported that they regularly screen for CI, and 23% reported that they never screen; however, 59% believed screening should be part of everyday practice. Nurses mostly screened when ward policy required admission/daily cognitive screening (34%) or when they suspected cognitive problems or decline (39%). Nurses in acute settings (vs non-acute) were nine times more likely to screen when adjusting for confounders. The typically used screening instruments assessed delirium/confusion and dementia but not milder CI. Common barriers to screening included communication difficulties, patients too unstable/unwell, time constraints requiring clinical care prioritisation, and being unaware of patients' normal cognition status.

CONCLUSIONS

Screening practices for CI in the context of ACS were found to be suboptimal, with only 16% of nurses in our sample reporting regularly screening. The most used methods focus on screening for delirium. Given current practice, many CI cases will be missed, especially mild CI, which will negatively affect secondary prevention efforts. Further research is required to identify appropriate methods to implement routine screening within the nursing clinical workflow and establish a suitable screening tool.

Documentation of cognitive impairment screening amongst older hospitalised Australians: a prospective clinical record audit

BACKGROUND

Failure to detect cognitive impairment (CI) in hospitalised older inpatients has serious medical and legal implications, including for the implementation of care planning. This mixed methods study aimed to determine amongst hospital in-patients aged ≥ 65 years: (1) Rates of documentation of screening for CI, including the factors associated with completion of screening; (2) Rates of undocumented CI amongst patients who had not received screening during their admission; (3) Healthcare provider practices and barriers related to CI screening.

METHODS

A mixed methods study incorporating a clinical audit and interviews with healthcare providers was conducted at one Australian public hospital. Patients were eligible for inclusion if they were aged 65 years and older and were admitted to a participating ward for a minimum of 48 h. Patient characteristics, whether CI screening had been documented, were extracted using a template. Patients who had not been screened for CI completed the Montreal Cognitive Assessment (MoCA) to determine cognitive status. Interviews were conducted with healthcare providers to understand practices and barriers to screening for CI.

RESULTS

Of the 165 patients included, 34.5% (n = 57) had screening for CI documented for their current admission. Patients aged > 85 years and those with two or more admissions had greater odds of having CI screening documented. Among patients without CI screening documented, 72% (n = 78) were identified as cognitively impaired. While healthcare providers agreed CI screening was beneficial, they identified lack of time and poor knowledge as barriers to undertaking screening.

CONCLUSIONS

CI is frequently unrecognised in the hospital setting which is a missed opportunity for the provision of appropriate care. Future research should identify feasible and effective strategies to increase implementation of CI screening in hospitals.

Effect of very early supported discharge versus usual care on activi-ties of daily living ability after mild stroke: a randomized controlled trial

OBJECTIVE

To examine the ability to perform basic and instrumental activities of daily life after very early supported discharge vs usual discharge and referral routine during the first year after mild stroke.

DESIGN

A secondary analysis of data from the Gothenburg Very Early Supported Discharge randomized controlled trial.  Patients: A total of 104 patients (56% men; mean (standard deviation) age 75 (11) years) who had experienced a first stroke classified as mild.

METHODS

The primary outcome was the Activities of Daily Living Taxonomy score. Stroke Impact Scale (activities of daily living, and mobility) scores was a secondary measure. Patients were randomized to either very early supported discharge with 4 weeks of home rehabilitation provided by a multidisciplinary stroke team, or a control group discharged according to usual routine (referral to primary care when needed). Assessments were performed at discharge, 4 weeks post-discharge, and 3 and 12 months post-stroke.

RESULTS

Instrumental activities of the Activities of Daily Living Taxonomy scores (the lower the better) in the very early supported discharge and control groups were median 4 and 6 (p = 0.039) at 4 weeks post-discharge and 3 and 4.5 (p = 0.013 at 3 months post-stroke, respectively. Stroke Impact Scale (Mobility) median scores (the higher the better) in the very early supported discharge and control groups at 3 months were 97 and 86 (p = 0.040), respectively. There were no group differences in the 2 outcomes at 12 months post-stroke.

CONCLUSION

Compared with usual discharge routine, team-based rehabilitation during the first month at home is beneficial for instrumental activity in the subacute phase, in patients with mild stroke. One year post-stroke both groups show equal results.

Association of cognitive function very early after stroke with subjective cognitive complaints after 3 months, a register-based study

OBJECTIVE

Cognitive deficits are commonly observed after stroke and have been associated with the cognitive decline and development of dementia in later stages. This study aimed to investigate whether cognition screened at acute stroke units could explain subjective cognitive complaints 3 months after stroke and evaluate how the severity of stroke and age could influence this association.

METHODS

In this register-based longitudinal study, data were retrieved from three Swedish registers between November 2014 and June 2019. Information on subjective cognitive complaints (SCC) was collected from the Riksstroke 3-month follow-up form, which were used to analyze the primary outcomes. Cognitive function screened using the Montreal Cognitive Assessment (MoCA) at acute stroke units was expressed as the primary independent variable.

RESULTS

Of the 1977 patients included in the study, 58% were males, the median age was 73 years, and 63% had a minor stroke. A total of 60% of patients had impaired cognition at acute stroke units (MoCA score, <26), of whom 40.3% reported at least 1 cognitive problem after 3 months. In adjusted binary regression analysis models, patients with normal cognitive function had lower odds for SCCs. This pattern was observed regardless of age and in patients with a minor stroke.

CONCLUSIONS

Intact cognition early after stroke was related to decreased odds of subjective cognitive complaints at the 3-month follow-up. This study highlights the importance of both early cognitive screening after stroke and subjective cognitive complaints, which have been shown to be associated with cognitive decline. Furthermore, we suggest the importance of discussing cognitive function with patients during regular follow-up in primary care, usually 3 months after stroke.

A register-based study on associations between pre-stroke physical activity and cognition early after stroke (part of PAPSIGOT)

The objective was to investigate if pre-stroke physical activity is associated with intact cognition early after stroke. The study design was a cross-sectional, register-based study. The study sample included 1111 adults with first stroke (mild or moderate severity) admitted to three Swedish stroke units. The main outcome was cognition. The associations of pre-stroke physical activity, age, sex, smoking, diabetes, atrial fibrillation, previous TIA, statin treatment, hypertension treatment, reperfusion therapies, stroke severity, and education on the outcome cognition were analyzed using binary logistic regression. Physical activity was assessed within 48 h of admittance, and cognition was screened during stroke unit care. The results were: mean age 70 years, 40% women, 61% pre-stroke physically active, and 53% with post-stroke cognitive impairment. Patients with pre-stroke light or moderate physical activity have higher odds for intact cognition compared to inactive: odds ratio (95% confidence interval) 1.32 (0.97-1.80) and 2.04 (1.18-3.53), respectively. In addition to pre-stroke physical activity, people with younger age, a higher level of education, less severe stroke (more mild than moderate), being non-diabetic, and non-smoking have higher odds for intact cognition. In conclusion physical activity before stroke is associated with intact cognition in patients with mild and moderate stroke.

Very Early Cognitive Screening and Self-Reported Feeling of Fatigue Three Months After Stroke

Stroke is a major cause of disability and the second leading cause of death worldwide. Post-stroke fatigue has been reported as one of the most limiting symptoms after a stroke. Early identification of risk factors for developing post-stroke fatigue is important for providing timely rehabilitation. A correlation has been found between fatigue and cognitive impairment after stroke, but 2 months after stroke at the earliest. In the present study, we examined whether cognitive function screening using the Montreal Cognitive Assessment (MoCA) very early after stroke could explain fatigue 3 months after stroke. A total of 311 stroke patients admitted to a comprehensive stroke unit in Sweden between 2011 and 2016 were included in this longitudinal study. Cognition was screened within 2 days after admission to the stroke unit. Data on self-reported feeling of fatigue were retrieved from Riksstroke's 3-month follow-up form. The data were analyzed using binary logistic regression. We found that the cognitive function in an acute phase after stroke could not explain self-reported feeling of fatigue in a later stage. The correlation between cognitive impairment and fatigue that has been reported may be detectable no earlier than the subacute phase of stroke. As previous studies have shown that functional outcome, severity of stroke, and sex also correlate with fatigue after stroke, we controlled for these variables in our analysis. In line with previous studies, we found that female patients had higher odds of experiencing fatigue. This is something that health care professionals should be aware of when working with stroke patients.